Primary health care is not just a service delivery platform – Authors' reply
Authors: Kara Hanson, Dina Balabanova, Timothy Powell-Jackson, Nouria Brikci, Darius Erlangga
Journal: The Lancet Global Health (2022)

We are grateful to Luke Allen for highlighting the importance of definitions and challenging our Commission's1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar choice to operationalise the definition of primary health care (PHC) as a service delivery platform. This is an issue that we revisited continuously during our deliberations as we were committed from the outset to the encompassing, and purposively political, vision of Alma Ata and Astana as health for all.The choice to focus on a platform approach was driven by the Commission's focus on financing PHC. To increase resources for PHC we needed to interrogate the practice of government budgeting, as that is the way that public funds are secured for PHC and how they flow through the health system. This inevitably meant a greater focus on the primary care, essential public-health functions, and community-health platform elements of WHO's operational framework. But even here we were limited by the evidence available on financing of essential public-health functions (which consists primarily of conceptual frameworks for financing common goods for health),2Soucat A Financing common goods for health: fundamental for health, the foundation for UHC.Health Syst Ref. 2019; 5: 263-267Crossref PubMed Scopus (11) Google Scholar and on financing community-health systems (for which the evidence focuses mostly on the dependence of community platforms on donor funding,3Dahn B Woldemariam AT Perry H et al.Strengthening primary health care through community health workers: Investment case and financing recommendations.https://chwcentral.org/wp-content/uploads/2015/09/CHW-Financing-FINAL-July-15-2015.pdfDate: 2015Date accessed: May 26, 2022Google Scholar and on how community health workers are paid).4Colvin CJ Hodgins S Perry HB Community health workers at the dawn of a new era: 8. Incentives and remuneration.Health Res Policy Sys. 2021; 19: 106Crossref PubMed Scopus (11) Google ScholarMultisectoral action has remained the weakness of PHC, and of the Sustainable Development Goals more generally. This might be precisely because of the difficulty of securing budgets when working across sectors. Authors have identified theoretical mechanisms for cofunding where programmes have multisectoral benefits,5Remme M Vassall A Lutz B Luna J Watts C Financing structural interventions: going beyond HIV-only value for money assessments.AIDS. 2014; 28: 425-434Crossref PubMed Scopus (39) Google Scholar but these have not been implemented in practice.As wider work on social determinants of health has shown, working across sectoral boundaries is challenging. Securing budgets for this work is even more difficult. Focusing on the technical and political levers to spend more and spend better on the PHC platforms that serve populations seemed to us a pragmatic way forward. We are grateful to Luke Allen for highlighting the importance of definitions and challenging our Commission's1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar choice to operationalise the definition of primary health care (PHC) as a service delivery platform. This is an issue that we revisited continuously during our deliberations as we were committed from the outset to the encompassing, and purposively political, vision of Alma Ata and Astana as health for all. The choice to focus on a platform approach was driven by the Commission's focus on financing PHC. To increase resources for PHC we needed to interrogate the practice of government budgeting, as that is the way that public funds are secured for PHC and how they flow through the health system. This inevitably meant a greater focus on the primary care, essential public-health functions, and community-health platform elements of WHO's operational framework. But even here we were limited by the evidence available on financing of essential public-health functions (which consists primarily of conceptual frameworks for financing common goods for health),2Soucat A Financing common goods for health: fundamental for health, the foundation for UHC.Health Syst Ref. 2019; 5: 263-267Crossref PubMed Scopus (11) Google Scholar and on financing community-health systems (for which the evidence focuses mostly on the dependence of community platforms on donor funding,3Dahn B Woldemariam AT Perry H et al.Strengthening primary health care through community health workers: Investment case and financing recommendations.https://chwcentral.org/wp-content/uploads/2015/09/CHW-Financing-FINAL-July-15-2015.pdfDate: 2015Date accessed: May 26, 2022Google Scholar and on how community health workers are paid).4Colvin CJ Hodgins S Perry HB Community health workers at the dawn of a new era: 8. Incentives and remuneration.Health Res Policy Sys. 2021; 19: 106Crossref PubMed Scopus (11) Google Scholar Multisectoral action has remained the weakness of PHC, and of the Sustainable Development Goals more generally. This might be precisely because of the difficulty of securing budgets when working across sectors. Authors have identified theoretical mechanisms for cofunding where programmes have multisectoral benefits,5Remme M Vassall A Lutz B Luna J Watts C Financing structural interventions: going beyond HIV-only value for money assessments.AIDS. 2014; 28: 425-434Crossref PubMed Scopus (39) Google Scholar but these have not been implemented in practice. As wider work on social determinants of health has shown, working across sectoral boundaries is challenging. Securing budgets for this work is even more difficult. Focusing on the technical and political levers to spend more and spend better on the PHC platforms that serve populations seemed to us a pragmatic way forward. KH, DB, NB, DE and TP-J were funded by a grant from the Bill & Melinda Gates Foundation. The Lancet Global Health Commission on financing primary health care: putting people at the centreThe COVID-19 pandemic has brought the need for well-functioning primary health care (PHC) into sharp focus. PHC is the best platform for providing basic health interventions (including effective management of non-communicable diseases) and essential public health functions. PHC is widely recognised as a key component of all high-performing health systems and is an essential foundation of universal health coverage. Full-Text PDF Open AccessPrimary health care is not just a service delivery platformI congratulate Kara Hanson and colleagues on the Lancet Global Health Commission on financing primary health care (PHC).1 Their focus on equity and people-focused systems is welcome, and the recommendations are excellent. However, their decision to define PHC as a service-delivery platform is a well trodden, but ultimately counterproductive shortcut. Full-Text PDF Open Access